Can a template for a patient's medical evaluation be created to include a History of Present Illness (HPI), Review of Systems (ROS), Physical Examination (PE), and a plan of care with at least 3 differential diagnoses and potential medications?

Creating a Clinical Documentation Template

Yes, a comprehensive template can be created that includes History of Present Illness (HPI), Review of Systems (ROS), Physical Examination (PE), and a plan of care with differential diagnoses and medications, following evidence-based structured approaches to patient evaluation.

History of Present Illness (HPI) Structure

The HPI should be structured chronologically to improve diagnostic reasoning and communication efficiency. 1

• Document the chief complaint and principal cognitive, behavioral, or physical symptoms in sequential order of onset 2
• Include timing elements: onset date, frequency, tempo, and nature of change over time 2
• Obtain information from both the patient and a reliable informant (family member or caregiver), as informant reports provide added value, particularly when cognitive impairment or loss of insight may be present 2
• Query for associated symptoms: nausea, vomiting, fatigue, fever, and other relevant manifestations 2
• Document recent activities, travel, exposures to ill persons, foods consumed, and environmental exposures (including tick exposure in febrile illness) 2
• Explore plausible relationships between events and presenting symptoms, including potential triggers or contextual features 2

Review of Systems (ROS) Template

A structured comprehensive survey of all major domains is critical because patients often lack the knowledge to represent changes or may under-report symptoms. 2

The ROS should systematically assess:

• Cognitive function: memory, attention, language, executive function 2
• Activities of daily living (ADLs) and instrumental ADLs (IADLs): changes in self-care, household management, financial management 2
• Mood and neuropsychiatric symptoms: depression, anxiety, apathy, agitation, hallucinations 2
• Sensory and motor function: vision, hearing, gait, balance, weakness 2
• Constitutional symptoms: fever, weight loss, fatigue 2
• Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain 2
• Musculoskeletal: joint pain, stiffness, muscle weakness 2
• Cardiovascular and respiratory: chest pain, dyspnea, palpitations 3

In immunocompromised patients, specifically test for Clostridioides difficile in cases of diarrhea with or without acute abdomen. 2

Physical Examination (PE) Components

The physical examination remains an important component of patient evaluation even when imaging and laboratory tests are readily available. 4

Document:

• Vital signs: temperature, blood pressure, heart rate, respiratory rate, oxygen saturation 2
• General appearance: level of consciousness, confusion, lethargy 2
• Skin examination: rash (note absence or presence, as rash may be absent early in rickettsial diseases) 2
• Cardiovascular examination: heart sounds, peripheral pulses 4
• Respiratory examination: breath sounds, work of breathing 3
• Abdominal examination: tenderness, guarding, rebound, bowel sounds 2
• Musculoskeletal examination: joint swelling, range of motion, muscle strength 2
• Neurological examination: mental status, cranial nerves, motor strength, sensory function, reflexes, gait 2

In patients with suspected inflammatory arthritis, examine all joints and skin, and check for symptoms of temporal arteritis including headache or visual disturbances. 2

Differential Diagnosis Framework

Include at least three differential diagnoses based on presenting signs, symptoms, and initial laboratory findings. 2

For a patient with fever, nausea, vomiting, and fatigue, consider:

1. Viral syndrome 2
2. Foodborne illness/gastroenteritis 2
3. Urinary tract infection 2

When thrombocytopenia and leukopenia are present with worsening clinical condition, expand the differential to include:

• Encephalitis 2
• Sepsis 2
• Tickborne rickettsial diseases (Rocky Mountain Spotted Fever, ehrlichiosis, anaplasmosis) 2

In immunocompromised patients with acute abdomen, consider:

• Neutropenic enterocolitis/typhlitis 2
• Cytomegalovirus colitis 2
• Clostridioides difficile colitis 2

Plan of Care with Medications

Base initial treatment on presenting signs and laboratory findings, even when specific diagnosis is pending. 2

Diagnostic Testing

• Complete blood count (CBC) to evaluate for leukopenia, thrombocytopenia, anemia 2
• Inflammatory markers: ESR, CRP 2
• Organ-specific tests: creatine kinase (CK) for myositis, troponin for cardiac involvement 2
• Cultures: blood, urine, stool as indicated 2
• Serologic assays and PCR for suspected infectious etiologies 2
• Imaging: contrast-enhanced CT scan is the most reliable exam for intra-abdominal disease in immunocompromised patients 2

Medication Management

For grade 1 inflammatory conditions (mild symptoms):

• Continue current therapy 2
• Initiate acetaminophen and/or NSAIDs for analgesia (if no contraindications) 2

For grade 2 inflammatory conditions (moderate symptoms limiting instrumental ADLs):

• Hold immune checkpoint inhibitors if applicable 2
• Initiate prednisone 10-20 mg/day orally 2
• Taper over 4-6 weeks if improvement occurs 2
• Refer to rheumatology if no improvement after 4 weeks 2

For grade 3-4 inflammatory conditions (severe symptoms limiting self-care ADLs):

• Hold immune checkpoint inhibitors permanently if myocardial involvement 2
• Initiate prednisone 0.5-1 mg/kg or methylprednisolone 1-2 mg/kg IV for severe compromise 2
• Consider hospitalization 2
• Urgent rheumatology or neurology consultation 2

For suspected rickettsial disease with fever of unknown cause:

• Initiate intravenous levofloxacin or oral doxycycline empirically 2
• Continue doxycycline if symptoms persist after initial treatment 2

For neutropenic enterocolitis:

• Broad-spectrum antibiotics and bowel rest 2
• Reserve surgery only for perforation or ischemia 2

For anxiety with dyspnea:

• Alprazolam for acute episodes (short-acting benzodiazepine) 3
• Buspirone 5 mg twice daily (maximum 20 mg three times daily) for chronic anxiety, particularly effective in patients with respiratory conditions 3

Follow-Up Plan

• Schedule return visit within 24-48 hours if symptoms do not improve 2
• Contact patient regarding laboratory results 2
• Reassess response to therapy and adjust treatment as needed 3
• Consider home monitoring (pulse oximetry) for objective assessment during symptomatic episodes 3

Common Pitfalls

Do not attribute all symptoms to a single diagnosis without thoroughly excluding other organic causes, especially in elderly or immunocompromised patients. 2, 3

• Clinical signs may not be reliable in immunocompromised patients; the greater the immunocompromise, the less reliable the signs 2
• Laboratory tests may not accurately reflect severity in immunocompromised patients 2
• Rash may be absent in early rickettsial diseases 2
• Dogs can serve as sentinels for Rocky Mountain Spotted Fever; inquire about pet illness 2
• Avoid long-term benzodiazepines due to dependence risk and potential respiratory depression in lung disease 3